Navigating the Affordable Care Act – What’s In a Health Insurance Plan?

Navigating th Affordable Care Act
Learn how the Affordable Care Act will affect you and your practice in this ongoing series from LOMAP.

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What made up an insurance plan before the Affordable Care Act varied widely, or was hard to ferret out with no comparison tool available. The Marketplace changes that by giving baseline requirements and putting all plans in one location, allowing for side by side comparison. Some of those old plans will still exist, because they will be grandfathered, but none of the plans found in the Marketplace have grandfathered components. If you get it at the Marketplace, you get a guarantee that a uniform set of essential health benefits will be in every plan.

Essential Health Benefits

The essential health benefits are:

  1. Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  2. Emergency services
  3. Hospitalization (such as surgery)
  4. Maternity and newborn care (care pre- and post- birth)
  5. Mental health and substance use disorder services, including behavioral health treatment (including counseling and psychotherapy)
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices (these help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services

Investigate the Money

Plans have so many monetary components, it can be mind boggling. Here are the main ones:

  1. Premiums. Your monthly payment. In employer plans, usually the employer pays a portion of this and you pay the other portion.
  2. Deductibles. Just like your car insurance, this is the amount you pay before your insurance starts to pick up the bill. The deductible may not apply to all services. It will count towards your total out-of-pocket costs.
  3. Out-of-pocket costs. This is not just your deductible. It also includes coinsurance and copyaments for covered services, as well as all costs for services not covered by the plan. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for individual plans and $12,700 for family plans, meaning that once that amount is reached, the plan covers 100% of your costs for that year.
  4. Cost sharing. Generally it includes only deductibles, coinsurance, and copayments, or similar charges. It does not include premiums (unless it is a Medicaid plan), balance billing amounts for non-network providers, or any costs for services not covered by the plan. If you are within income ranges, get a plan through the Marketplace, and choose a Silver plan, you may qualify for a cost sharing reduction.
  5. Copays. Many of us know what this is: A fixed amount you pay, usually when you get the service. It is applied toward calculating your out-of-pocket costs and your deductibles, but can vary depending on where and when you get the service.

The final thing we can compare at the Marketplace is the level the plan comes in under, which designates a general set of prices for a general level of care. Federal plans say there are Bronze, Silver, Gold, and Platinum plans. Washington’s Marketplace has no platinum levels at this time, so one is choosing between Bronze, Silver, and Gold. (There are also catastrophic plans for under 30 individuals who can prove a hardship exemption. More on this in a future Navigating the Affordable Care Act post.)

Deciding the best plan for you will depend on your health and financial situation.  Generally, if you expect more medical costs, a Gold plan would benefit you more than a Silver; and if you are healthier, a Bronze plan would likely fit better. Any plan you sign up for this year will give you coverage starting January 1, 2014.

Tell us what you most want to know about the ACA today by commenting or emailing us at We will do our best to incorporate your questions and feedback into this ongoing Navigating the ACA series.

Navigating the Affordable Care Act

Navigating th Affordable Care ActNavigating the Affordable Care Act is an ongoing series from the WSBA Law Office Management Assistance Program designed to help solo and small practitioners understand the Affordable Care Act and how it affects them.

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